Teaching and assessing competency in retinal lasers in ophthalmology residency

BACKGROUND AND OBJECTIVE: The Accreditation Council for Graduate Medical Education has mandated that residency programs teach and assess six specific competencies (ie, medical knowledge, patient care, communication and interpersonal skills, professionalism, practice-based learning, and systems-based learning). To the authors' knowledge, there is no standardized and widely used curriculum for teaching and assessing resident competencies in retinal lasers. METHODS: The pertinent literature on resident education in retinal lasers is reviewed and specific "good practices" for teaching and assessing laser competency are presented. RESULTS: Development and deployment of educational tools that teach and assess laser competency simultaneously; are reliable, reproducible, and valid; have low faculty time burden; and are affordable, generalizable, and fair are recommended. CONCLUSION: Retinal laser competency can be taught and assessed in ophthalmology residency training programs. Future research will be needed to provide evidence that these teaching and assessment tools produce improved educational and patient outcomes and provide verifiable, reliable, and valid evidence of resident competence in retinal lasers.     

The ACGME Outcome Project in Ophthalmology: Practical Recommendations for Overcoming the Barriers to Local Implementation of the National Mandate

The Accreditation Council for Graduate Medical Education (ACGME) Outcome project is a well-defined, 10-year, ambitious national mandate to improve resident education through the teaching and assessing of six general competencies (i.e., patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice). Over the past 5 years a Task Force at the University of Iowa has deployed 10 major competency assessment tools: 1) the University of Iowa residency curriculum; 2) direct observation using the Ophthalmic Clinical Exercise (OCEX); 3) journal club; 4) multi-source evaluation; 5) a modified Dreyfus scale faculty global evaluation form; 6) the Iowa Cataract surgical curriculum; 7) the Iowa Ophthalmic Laser curriculum; 8) traditional written and oral examinations; 9) self reflection exercises and projects; and 10) learner portfolio. We report our 5-year experience with an implementation matrix for translating the national ACGME mandate into local compliance. We identify the barriers encountered by our Task Force in local implementation and propose practice solutions based upon our experience for overcoming the cultural, institutional, financial, and other barriers to success. We hope that our institutional work and experience will stimulate other programs to participate more fully in the ACGME Outcomes Project.     

Implementing a structured oral examination into a residency program: getting started.

BACKGROUND AND OBJECTIVE: To describe the steps involved in implementing a structured oral examination into a residency program PATIENTS AND METHODS: Existing oral examination format was evaluated and deficiencies addressed by creating a structured examination and increasing the frequency of administration to ophthalmology residents at the University of Arkansas for Medical Sciences. RESULTS: A structured oral examination was implemented. It provided both a realistic simulation of the board certification examination and a process that was a useful teaching method and assessment tool. It was valuable in addressing the Accreditation Council for Graduate Medical Education (ACGME) competencies. CONCLUSIONS: Oral examinations can be a versatile means of teaching and assessing resident physicians. Although the implementation process can be onerous, once in place, it can become an efficient tool for assessing all categories of the ACGME competencies and can provide valuable training in oral examination performance.     

Should ophthalmologists receive communication skills training in breaking bad news?

Background: Effective communication is essential in the delivery of health care. The purpose of the present study was to determine whether formal communication skills training in breaking bad news should be incorporated into the training of ophthalmologists. Methods: An online survey was offered to every member of the Canadian Ophthalmological Society (COS) with a registered email address. Survey questions focused on 2 specific scenarios: (S1) disclosing permanent vision loss to a patient and (S2) revoking a patient's driver's licence. Main outcome measures were the respondents' opinions on the need for and benefit of including communication skills in the training of ophthalmologists and, if considered necessary, its optimal format and point in their training. Results: The response rate was 28% (225/800). The vast majority of respondents believed that it is important for ophthalmologists to be able to communicate effectively when breaking bad news (S1: 99%, mean Likert score 4.81; S2: 97%, 4.73); that communication skills training would be beneficial in breaking bad news for both future ophthalmologists (S1: 88%, 4.28; S2: 87%, 4.24) and patients (S1: 92%, 4.26; S2: 87%, 4.24); and that it should be included in the training of ophthalmologists (S1: 87%, 4.27; S2: 83%, 4.15). Residency was the preferred point in training (95% for both scenarios), but there was no consensus on what type of training format(s) to use. Interpretation: Survey respondents strongly support the inclusion during ophthalmology residency of formal communication skills training in breaking bad news. This would be a logical choice of content for ophthalmology residency programs striving to meet the mandated "interpersonal and communication skills" core competency requirements.     

眼科青年医师的综合培养

对于眼科青年医师的培养,除了本专业学习培养外,还要掌握其他相关科室的基本技能,在技能培训过程中要克服压力,积极乐观的心态对眼科技能学习有很大帮助。同时良好的医患沟通非常重要,掌握必要的沟通技巧。此外,培养青年医师良好的科研思维和创新意识对于眼科的创新发展至关重要。（眼科,2017, 26：286-288）     

Teaching and assessing surgical competency in ophthalmology training programs.

BACKGROUND AND OBJECTIVE: The Accreditation Council for Graduate Medical Education (ACGME) has mandated implementation of six new competencies in resident training in the United States. An implementation strategy is proposed to teach and assess cataract surgical competence. PATIENTS AND METHODS: An intradepartmental Task Force for the ACGME competencies reviewed the literature for assessment tools to develop an implementation matrix for assessing surgical competence. RESULTS: "Good practices" (gleaned from the literature) were adapted for the institution's needs and tested, including (1) written and explicit goals or objectives for each stage of training; (2) substitution of a criterion-referenced (Dreyfus model) scoring rubric for a norm-referenced, peer-benchmarked global evaluation; (3) use of formative rather than summative feedback; (4) incorporation of deliberate practice (Ericsson model); and (5) portfolio-based documentation of sentinel event markers and remediation. CONCLUSION: An implementation matrix for teaching and assessing surgical competence might be useful for local compliance with the ACGME mandate.     

眼科显微手术技能培训模式探讨

目的：探索一种眼科专科医师显微手术技能培训模式,使年轻的眼科医生了解并掌握眼科显微手术的基本特征、基本知识和基本技能, 以适应眼科临床工作的需要。 方法：对尚未熟练掌握眼科显微手术的本院眼科医生、进修医生和实习研究生进行眼科显微手术基础理论和操作技能培训,并建立起严格的培训制度。 结果：培训者46名基本显微手术操作比较准确和熟练,能在带教老师指导下应用手术显微镜完成翼状胬肉切除、白内障囊外摘出+人工晶状体植入术、青光眼小梁切除等手术操作。 结论：利用眼科显微手术培训平台进行显微手术技能培训,并将理论与实践相结合的这种培训模式,能达到掌握眼科显微手术操作的目的。     

Using the Journal Club to teach and assess competence in practice-based learning and improvement: a literature review and recommendation for implementation

The traditional journal club has historically been used to teach residents about critically reading and reviewing the literature in order to improve patient care. The Accreditation Council for Graduate Medical Education competencies mandate requires that ophthalmology residency programs both teach and assess practice-based learning and improvement. A systematically conducted review of the literature regarding the use of the journal club in resident medical education was performed to define specific recommendations for implementation of a journal club tool. Selected best practices for a successful journal club were gleaned from the existing medical literature. These include the following: 1) the use of a structured review checklist, 2) explicit written learning objectives, and 3) a formalized meeting structure and process. The journal club might prove to be an excellent tool for the assessment of competencies like practice-based learning which may be difficult to assess by other means. Future study is necessary to determine if journal club can improve educational outcomes and promote lifelong competence in practice-based learning.     

Teaching and assessing systems-based competency in ophthalmology residency training programs

The Accreditation Council for Graduate Medical Education (ACGME) has mandated that residency programs, including ophthalmology, teach and assess specific competencies, including systems-based learning. We review the pertinent literature on systems-based learning for ophthalmology and recommend specific “good practices” to manage the ACGME mandate. Tools are required that both teach and assess systems based learning competency simultaneously, that are reliable and valid, that have low faculty burden, and that are affordable, practical, and fair. Future research should provide evidence that these interventions produce improved educational and patient outcomes and show proof of competence in systems based learning among residents and clinicians in practice.     

Cataract surgery training using surgical simulators and wet-labs: Course description and literature review

Cataract surgery is the most common surgery to face the ophthalmology training resident. To facilitate achieving surgical competency and reduce complication rates, wet laboratories and surgical simulators are used in surgical disciplines worldwide. We developed a simulator and wet-lab course that aims to build the microsurgery skills of trainees and improve safety during real surgical procedures. Herewith, we describe the standardized hands-on course that incorporates these tools for advanced training. Additionally, we review the literature on wet-lab and surgical simulators in ophthalmology, focusing on their importance in training centers. The course is offered four times per year since it started in December 2015, and t total of 88 trainees participated to date. Feedback received from the trainees’ supervising surgeons showed that this course addresses a major training challenge, and that a permanent version of this course should be established at each training center. We suggest incorporating fixed wet-lab and surgical simulator competencies in ophthalmology training programs. Additionally, we recommend that residents be allowed to operate on real patients only after passing the course. We believe that these steps would foster ophthalmologists with advanced training, decrease their learning curve, and empower them to safely conduct cataract surgery with low complication rates.     

Teaching and assessing professionalism in ophthalmology residency training programs

The Accreditation Council for Graduate Medical Education (ACGME) has mandated that all residency training programs teach and assess new competencies including professionalism. This article reviews the literature on medical professionalism, describes good practices gleaned from published works, and proposes an implementation matrix of specific tools for teaching and assessing professionalism in ophthalmology residency. Professionalism requirements have been defined by the ACGME, subspecialty organizations, and other certifying and credentialing organizations. Teaching, role modeling, and assessing the competency of professionalism are important tasks in managing the ACGME mandate. Future work should focus on the field testing of tools for validity, reliability, feasibility, and cost-effectiveness.     

An update on the novel approaches towards skills assessment of ophthalmology residents in the Indian scenario

An essential part of the teaching-learning paradigm is assessment. It is one of the ways to achieve feedback for the various methods that have been used to impart a particular skill. This is true of ophthalmology training, where various clinical and surgical skills are learned as part of the residency program. In preparation for residents to become proficient ophthalmologists, both formative and summative assessments are of paramount importance. At present, assessment is primarily summative in the form of a university examination, including theory and practical examinations that are conducted at the end of the three years of residency. A formative assessment can make course corrections early on, allowing for an improved understanding of the subject and the acquisition of clinical and surgical skills. Formative assessments also allow us to customize the teaching methodology considering individual residents’ learning capabilities. In addition, formative assessments have the advantage of alleviating the stress of a “final” examination, which could sometimes result in a less-than-optimum performance by the residents. The COVID-19 pandemic has forced us to adopt new teaching methods, which has led to the adoption of changes in assessment. In this regard, we discuss the different assessment tools available, their pros and cons, and how best these tools can be made applicable in the setting of an ophthalmology residency program.     

Determining Ontario's supply and requirements for ophthalmologists in 2000 and 2005: 2. A comparison of projected supply and requirements.

BACKGROUND: To determine whether the projected supply of ophthalmologists in 2000 and 2005 in Ontario will be matched by the predicted requirements. METHODS: Described in the accompanying paper (page 74). RESULTS: Multiple regression analysis predicted a supply of 485 +/- 15 full-time-equivalent (FTE) ophthalmologists in 2000 and 476 +/- 14 FTEs in 2005. Except for the needs-based method of determining requirements, which generated a figure of 524 +/- 16 to 533 +/- 16 FTEs, the requirement methods yielded estimates that were within the range of the projected supply for 2000 (physician:population ratio method 458, utilization-based method 500 +/- 15 and substitution method 470 +/- 14 to 490 +/- 15). For 2005, only the physician:population ratio method gave an FTE requirement estimate (489) that was in keeping with the projected supply. The other models gave FTE estimates that were higher than the projected supply (utilization-based model 559 +/- 17, substitution model 526 +/- 16 to 548 +/- 16, and needs-based model 585 +/- 18 to 596 +/- 18). INTERPRETATION: The reduction in the number of ophthalmology residents in Ontario that began in 1994 will not affect the short-term requirements for ophthalmologists but may result in fewer ophthalmologists than will be necessary to fulfil Ontario's requirements in 2005 and beyond. Possible solutions include doubling the number of residency positions beginning in 1999.     

3D vs 2D qualitative and semiquantitative evaluation of the glaucomatous optic disc atrophy using computer-assisted stereophotography

BACKGROUND AND PURPOSE: Real colour documentation of the optic nerve head (ONH) is one of the most important methods to identify the early progression of glaucomatous optic nerve damage. This study compares the qualitative and semiquantitative evaluation of ONH photographs, using a 3D time-multiplexing system and conventional 2D photography, visualised on a computer monitor.PATIENTS AND METHODS: Stereophotographs of the ONH were converted by special software in a 3D file. The same images were shown in 2D and 3D to 22 subjects with different training grades (residents and ophthalmologists). The evaluation based on a standardised questionnaire, containing semiquantitative parameters of the ONH. A weighted score for quality of ONH assessment counted the correct answers of the observers to compare their evaluation in 2D to the one made in 3D. RESULTS: All of the observers achieved a significant better evaluation of the ONH with 3D than with 2D images. No significant differences were observed between both groups. Classification errors with respect to the 'gold standard' were lower for 3D measurements as compared with 2D measurements (P=0.007). No significant differences were observed between the gold standard and residents or ophthalmologists for the ONH size, but for the c/dratio the stereoscopic images lead to better results.CONCLUSION: This study showed a better evaluation of parameters associated with the glaucomatous ONH atrophy with 3D images compared with 2D, independent of the clinical training grade. The computer-based evaluation of the ONH atrophy by using a time-multiplexing system (shutter-glasses) may improve the diagnosis of glaucoma patients.     

Re-engineering the resident applicant selection process in ophthalmology: a literature review and recommendations for improvement

The current resident selection process for ophthalmology has undergone little change over the last several years and remains highly dependent on the traditional selection factors (i.e., grades, honors, letters of recommendation, and an interview). Unfortunately, these selection factors have not been shown to be consistently predictive of future resident performance. In addition, the Accreditation Council for Graduate Medical Education (ACGME) has mandated implementation of six new competencies in resident training in the USA and the current selection process does not directly recruit for these competencies. We propose an implementation strategy to re-engineer and improve the resident selection process in ophthalmology and potentially develop assessments that would be predictive of actual downstream resident performance that would encompass the ACGME related competencies. An intra-departmental Task Force for the ACGME Competencies reviewed a PubMed literature search regarding resident selection. A content expert (AGL) gleaned selected “good practices” from the literature review and summarized the results. Specific recommendations were reviewed for topicality to ophthalmology and where possible for feasibility, reliability, and validity. We summarize several good practices identified from the literature review and propose an implementation matrix for aligning the resident application process with the ACGME competencies that might include: using a standardized and consolidated academic score for the cognitive domains; converting the letter of recommendation format into a letter of evaluation; standardizing the letters of evaluation, including the “Dean's letter”; using behavior specific interview techniques with standardized questions; and developing a specialty based consensus for the selection of traits specific to ophthalmology that might predict success. The resident selection process for ophthalmology might be improved by implementation of specific good practices from the literature. Ophthalmology should strive to develop applicant selection tools that might be useful for predicting residency performance and that would align with the ACGME competency mandate for tools to predict future performance as a physician.     

Training Indian ophthalmologists in phacoemulsification surgery: Nine-year results of a unique two-week multicentric training program

Purpose:To assess the outcome of 2 weeks phacoemulsification training program that is a unique collaboration between premier ophthalmic training institutes of India and Alcon Inc. initiated 10 years ago.Methods:Cataract surgeons eager to adopt phacoemulsification surgery as the primary treatment modality were enrolled in an intensive 2 weeks training program across seven premier ophthalmic institutes in India. These surgeons performed supervised phacoemulsification surgery under the guidance of expert faculty. Simultaneously didactic lectures, postoperative video discussions, and wet laboratory training were conducted. To assess improvement in the surgical skills each surgery was scored using the International Council of Ophthalmology-Ophthalmology Surgical Competency Assessment Rubrics (ICO-OSCAR). Phaco Development Specialist supported these surgeons for minimum duration of 1 year and maximum of 9 years and 2 months. In this multicentric study, surgical data of the participants enrolled between June 2010 to August 2018 was retrospectively analyzed.Results:Nine hundred 89 ophthalmologists across 27 Indian states and 4 Union Territories were trained between June 2010 and August 2018. The mean age of participants was 40.6 (+ 8.2 years) and 64.8% were males. After completing their training they performed 1,022,508 phacoemulsification surgeries in 9 years and 2 months. At follow-up, 92.11% and 88.77% of the surgeons were performing phacoemulsification at the end of 1 year and final follow-up, respectively.Conclusion:This program highlights how partnership model between industry and ophthalmologists can go hand in hand for training and skill development of doctors contributing to much-needed improvement in patient care across societies.     

Microsurgical lab testing is a reliable method for assessing ophthalmology residents' surgical skills

Background

Formal assessment of clinical competencies is necessary to ensure that all residents are acquiring important skills and, in the United States, will soon become a requirement for residency programme accreditation by the Accreditation Council for Graduate Medical Education (ACGME). The Eye Surgical Skills Assessment Test (ESSAT), a laboratory‐based surgical skills obstacle course, was developed in response to the need for improved tools for the assessment of surgical skills during residency. The ESSAT has previously been shown to have face and content validity, and in this study we sought to determine its inter‐rater reliability and, to some extent, its construct validity.

Methods

Twenty‐seven content experts (residency programme directors and faculty members involved with resident surgical training) watched videos of a junior resident and senior resident completing the three ESSAT stations (skin suturing, muscle recession, and phacoemulsification: wound construction & suturing technique) and completed assessment forms, both task‐specific checklists and a global rating scale of performance.

Results

The ESSAT showed strong inter‐rater reliability for determining whether a resident “passed” a threshold of competency at each station for both the checklists and global rating scale. In addition, for each station, the senior resident was consistently rated above a “passing” threshold using either assessment form, whereas the junior resident was more often rated below (94% vs 30% passing on completed forms).

Conclusion

These results, along with the findings of our face and content validity analysis, support the reliability and validity of the ESSAT, and indicate that it could be a useful tool for improving the assessment of surgical skill during residency. The ESSAT is a tool that all residency programmes could implement as a part of their ophthalmic surgical curriculum and competency assessment, and may be useful to set a threshold of competence that all residents would need to achieve prior to entering the operating room.New assessment tools are needed to improve the process of teaching and evaluating residents in core competencies. In the United States, this need has become a mandate, as the Accreditation Council for Graduate Medical Education (ACGME) has set forth a timeline by which all residency programmes, in order to maintain their accreditation, must develop and integrate new tools for teaching and evaluating residents in six core competencies.¹ Surgical skills was added as a seventh competency by the American Board of Ophthalmology.² The Eye Surgical Skills Assessment Test (ESSAT) was developed both as a response to these mandates and to the need for more objective and structured methods of assessing residents'' surgical skills. In ophthalmology, several new surgical skills assessment tools have recently been developed: in addition to the wet lab‐based ESSAT, programmes will have in their armamentarium procedure specific evaluation forms (which many programmes have already been using), assessment of OR performance with videos as well as specific forms^3,4 and simulation technology.^5,6Modelled after the Objective Structured Assessment of Technical Skills (OSATS), a laboratory‐based surgical skills‐assessment test developed⁷ and validated⁸ by researchers in the field of general surgery, the ESSAT is made up of three simulated surgical tasks that the resident is required to complete in the microsurgical laboratory. These tasks are (1) skin suturing, (2) muscle recession and (3) phacoemulsification: a wound construction & suturing technique. The resident''s performance may be observed live or on videotape by a surgical educator who completes a task‐specific checklist as well as a global rating scale of performance for each task.The ESSAT offers the controlled setting of the microsurgical laboratory for residents to learn and be assessed in a standardised fashion. In addition, the ESSAT takes skills assessment and basic competency determination out of the operating room, where patient risks become involved. We previously established that the ESSAT has face and content validity by surveying experts in the field and incorporating their suggestions for improving the ESSAT.⁹ To ensure that the ESSAT has the test characteristics needed of a good assessment tool (ie, validity, reliability), we set forth in this study to also establish the inter‐rater reliability and, to a limited degree, the construct validity of the ESSAT, particularly for the purpose of establishing a threshold of basic skills competency that all residents must achieve in order to enter the operating room.     

裂隙灯照相及手术录像系统在眼表疾病临床教学中的应用

眼表疾病的诊断是住院医师最需掌握的课程,而眼表手术也是最易入门的操作之一,但因患者及手术条件的限制,眼表疾病教学并不容易实施。裂隙灯显微镜照相系统及手术显微镜录像采集系统不但可满足多位住院医师对同一病例的观察,也可将资料存档反复观看,使住院医师对疾病诊断及手术操作有具体化认识。在使用录像及照相系统教学时,应同时联合动物眼球的操作培训、教学会议等其他教学方式,以便对住院医师进行全面的培养。（眼科,2016, 25： 423-425）     

The Ophthalmic Clinical Evaluation Exercise (OCEX)

PURPOSE: New concise tools must be developed to assess reliably and validly the core residency competencies identified by the Accreditation Council for Graduate Medical Education. PARTICIPANTS: Eighteen content experts (residency program directors). METHODS: A 1-page Ophthalmic Clinical Exercise Examination (OCEX) checklist, for use during observed resident-patient interactions, was developed by an American Board of Ophthalmology taskforce. The OCEX checklist was sent to 18 content experts for their review and constructive comments. RESULTS: Experts' comments were incorporated, establishing face and content validity. CONCLUSIONS: The OCEX has face and content validity. It can be used to assess a resident's patient care skills, medical knowledge, and interpersonal skills. Reliability and predictive validity still need to be determined.     

现阶段眼科住院医师临床技能培训的几点思考

目前眼科住院医师临床技能培训中存在的问题体现在医疗环境总体状况不利、眼科带教老师的积极性尚需提高、眼科住院医师的自律性和学习积极性有待加强。在现阶段的医疗环境下,为顺利完成眼科住院医师的临床技能培训,眼科住院医师应加强眼科理论基本功的掌握,充分利用眼科手术与诊断治疗操作的辅助教学系统,以积极主动的心态参与临床技能操作,以循序渐进的方式进行眼科技能训练。（眼科,2013,22：67-69）